Nutrition

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nutrient needs during pregnancy

They increase to support growth and maintain maternal homeostasis, particularly during the 2nd and 3rd trimesters. During the last 2 trimesters, normal-weight women need approximately 300 extra calories per day. Key nutrient needs include protein, calories, iron, folic acid, calcium, and iodine. Caloric needs (and protein) are higher for lactation than pregnancy, and the nutritional quality of breast milk is maintained at the expense of maternal nutrition if dietary intake is inadequate.

alcohol abuse

The toxic effect of alcohol on the intestinal mucosa interferes with normal nutrient absorption; thus, requirements increase as the efficiency of absorption decreases. Need for B vitamins increases because they are used to metabolize alcohol. Alcohol can also influence nutrient metabolism by impairing nutrient storage, increasing nutrient catabolism, and increasing nutrient excretion. Alcohol abuse that results in liver damage has profound effects on the body’s nutrient metabolism and requirements.

nutrition with older adult

Because of the decreases in BMR and physical activity and loss of lean body mass, energy expenditure decreases. Loss of teeth and periodontal disease may make chewing more difficult. A decrease in peristalsis can result in constipation. Loss of taste between sweet and salty begins between 55 and 59 years of age, but discrimination between bitter and sour remains intact. The sensation of thirst also decreases. Degenerative diseases and the use of medications are more common with aging. It is not uncommon for social isolation, poor self-esteem, or loss of independence to affect nutritional intake negatively. Because of the changes related to aging, the caloric needs of the body decrease. The need for nutrients, however, stays the same or increases. Foods that are difficult to chew may need to be eliminated, whereas an increase in fiber and fluid intake can relieve constipation. Elderly people are also prone to dehydration, and lack of interest in eating is common. Nutrient intake, digestion, absorption, metabolism, or excretion may be altered because of the physiologic changes common to this age. Dietary restrictions related to chronic illness, limited income, isolation, and age-related physiologic changes place persons in this age group at risk for malnutrition.

nutrient needs r/t gender

Men differ from women in their nutrient requirements due to differences in body composition and reproductive function. Their larger muscle mass translates into higher caloric and protein requirements (therefore, slightly higher needs for B vitamins that metabolize calories and protein) because muscle is more metabolically active than adipose tissue (women have proportionately more adipose tissue). Women of childbearing age have higher iron requirements related to menstruation.

catabolism

Tissues are continuously being broken down (body's protein tissues)

anabolism

Tissues are continuously being replaced

Nitrogen balance

a comparison between catabolism and anabolism, can be measured by comparing nitrogen intake (protein intake) and nitrogen excretion (nitrogen lost in urine, urea, feces, hair, nails, skin). When catabolism and anabolism are occurring at the same rate, as in healthy adults, the body is in a state of neutral nitrogen balance (i.e., nitrogen intake equals nitrogen excretion).

negative nitrogen balance

exists when excretion of nitrogen exceeds the intake. Example: starvation and the catabolism that immediately follows surgery, illness, trauma, and stress.

positive nitrogen balance

when nitrogen intake is greater than excretion. Examples: during periods of growth, pregnancy, lactation, and recovery from illness.

absorption

the digested nutrients are then transferred into the person's circulation to be transported throughout the body after it's digested. Most absorption of digested food and minerals, and some absorption of water, occurs through the walls of the small intestine. Undigested waste materials continue through the GI tract and are eliminated.

anorexia

the lack of appetite, may be related to systemic and local diseases; numerous psychosocial causes, such as fear, anxiety, depression, pain; and impaired ability to smell and taste—or it may occur secondary to drug therapy or medical treatments. Others who may have limited food intake include those who have difficulty chewing and swallowing, those who experience chronic GI problems or undergo certain surgical procedures, those with certain chronic illnesses (such as cancer), and those with inadequate food budgets.

used to determine body dimensions. In children, anthropometric measurements are used to assess growth rate; in adults, they can give indirect measurements of body protein and fat stores. For the data to be accurate and reliable, standardized equipment and procedures must be used, and the data must be compared with the appropriate reference standards for the pt's age and sex. Height and weight, the most common anthropometric measurements, are obtained when the pt is admitted to the HC facility and periodically thereafter or assessed in a home care environment. Weigh a pt on the same scale each time and at the same time of day, preferably before breakfast. Height and weight are used to calculate the patient’s BMI. Because actual weight may be increased if the patient has edema, consider hydration status. Although self-reported weight may be recorded when actual weight is unobtainable, it is highly inaccurate and must be noted. Record an actual weight as soon as feasibly possible. Self reported height in the elderly can be inaccurate related to shortening of the spine. Record an actual height as soon as possible. Additional anthropometric measurements include triceps skin-fold measurements, a measure of subcutaneous fat stores; midarm circumference, a measure of skeletal muscle mass; and midarm muscle circumference, a measure of both skeletal muscle mass and fat stores.

aspiration

the misdirection of oropharyngeal secretions or gastric contents into the larynx and lower resp tract. Dysphagia is associated with an increased risk of aspiration.

basal metabolism

the energy required to carry on the involuntary activities of the body at rest--the energy needed to sustain the metabolic activities of cells and tissues. These activities include actions such as maintaining body temp and muscle tone, producing and releasing secretions, propelling food through the GI tract, inflating the lungs, and contracting the heart muscle. As the amount of energy used on physical activity declines, the proportion of cal used for basal metabolism increases; it accounts for more than half of most people's total energy requirements. Because of their larger muscle mass, men have a higher BMR than women. BMR is about 1 cal/kg of body weight per hour for men and 0.9 cal/kg per hour for women. Other factors that increase BMR include growth, infections, fever, emotional tension, extreme environmental temps, and elevated lvls of certain hormones. Aging, prolonged fasting, and sleep all decrease BMR. Most nutritionists agree that fasting or following a very-low cal diet defeats a weight-loss plan because the body interprets this eating pattern as starvation and compensates by slowing down the resting metabolic rate, making it even more difficult to lose weight.

body mass index (BMI), or Quetelet Index

is a ratio of weight (in kilograms) to height (in meters). The BMI is a reliable indicator of total body fat stores in the general population. Health practitioners use this more accurate weight calculation as an initial assessment of nutritional status. The BMI does not differentiate according to gender and is calculated in the following manner: Using kilograms and meters:

BMI= weight in kg/(height in meters)X(height in meters)

BMI also provides an estimation of relative risk for diseases such as heart disease, diabetes, and hypertension. However, it is important to note the BMI may not be accurate for people such as athletes, with a large muscle mass, or people with edema or dehydration, and older persons and others who have lost muscle mass. A person with a BMI below 18.5 is underweight, a BMI of 25 to 29.9 indicates an overweight individual, a BMI of 30 or greater indicates obesity, and a BMI of 40 or greater indicates extreme obesity.

method of calculating calorie requirements

• Estimate the basal metabolic rate (BMR) or the amount of calories necessary to maintain the body at rest. Because menusually have a greater muscle mass than women, their caloric requirements are slightly higher. A rule-of-thumb guideline for calculating BMR is to multiply healthy weight (in pounds) by 10 for women and 11 for men. For a person who is overweight, multiply by the average weight within the healthy weight range. For example:

• 1.5 High activity: active in physical sports or a labor intensive occupation, such as construction work

• Multiply the BMR by the number associated with the activity level. For example, the above female’s BMR = 1,300 calories per day. She engages in light activity.

1,300 X 1.3 = 1,690 total daily calories

A significant intentional or unintentional change in the patient’s weight can also indicate poor nutritional status and/or health problems. Significant weight change is determined by how much weight is lost per unit of time. To calculate the percent of weight change, use the following formula.

usual weight - present weight / usual weight X 100

Weight loss is considered significant if it falls into the following guidelines:

• 1% to 2% in 1 week

• 5% in 1 month

• 7.5% in 3 months

• 10% in 6 months

bulimia

eating disorder characterized by gorging followed by purging with self-induced vomiting, diuretics ,and laxatives, also becomes more common in teenagers.

calories, or cal

energy in the diet. Only carbs, protein, and fat provide energy. (Vitamins and minerals, needed for the metabolism of energy, do not provide calories.)

total daily energy expenditure

the sum of all the calories used to perform physical activity, maintain basal metabolism, and digest, absorb, and metabolize food. If a person's daily energy intake is equal to total daily energy expenditure, the person's weight will remain stable. However, if the energy intake is less than the energy expended, the person's weight will decrease. If the energy intake exceed energy expenditure, weight will increase.

carbohydrate

commonly known as sugars and starches, are organic compounds composed of carbon, hydrogen, and oxygen. They serve as the structural framework of plants. The only animal source of carbohydrate in the diet is lactose, or “milk sugar.” The significance of carbohydrates cannot be overstated. They are relatively easy to produce and store, making them the most abundant and least expensive source of calories in the diet worldwide. In countries where grains are the dietary staple, carbohydrates may contribute as much as 90% of total calories. Carbohydrate intake is often correlated to income. As income increases, carbohydrate intake decreases and protein intake, a more expensive form of energy, increases.

cholesterol

is a fatlike substance found only in animal products. It is not an essential nutrient; the body makes sufficient amounts. Cholesterol is an important component of cell membranes and is especially abundant in brain and nerve cells. It also is used to synthesize bile acids and is a precursor of the steroid hormones and vitamin D. Although cholesterol serves many important functions in the body, high serum levels are clearly associated with an increased risk for atherosclerosis. To help lower serum cholesterol levels, researchers recommend limiting cholesterol intake, eating less total fat—especially saturated and trans fat—eating more unsaturated fat, and increasing fiber intake, which increases fecal excretion of cholesterol.

saturated fats vs

Food fats contain mixtures of saturated and unsaturated fatty acids. The difference in degree of saturation depends on the amount of hydrogen in fat molecules. Saturated fats containmore hydrogen than unsaturated fats. Most animal fatsare considered saturated and have a solid consistency at roomtemperature. Conversely, most vegetable fats are consideredunsaturated, remain liquid at room temperature, and arereferred to as oils. Saturated fats tend to raise serum cholesterollevels, whereas unsaturated fats lower serum cholesterollevels.

clear liquid diet

contain only foods that are clear liquids at room or body temperature—gelatin, fat-free broth, bouillon, ice pops, clear juices, carbonated beverages, regular and decaffeinated coffee, and tea. Because clear liquid diets are inadequate in calories, protein, and most nutrients, progression to more nutritious alternatives is recommended as soon as possible.

digestion

dysphagia

difficulty swallowing/the inability to swallow. (barrier to eating) Can be the result of poor dental health, cancer, or a neurologic dz, such as stroke, Parkinson's dz, or dementia, and may reduce the pt's nutritional intake.

special considerations and interventions for feeding pts with dysphagia

• Provide at least a 30-minute rest period prior to mealtime. A rested person will likely have less difficulty swallowing

• Sit the patient upright, preferably in a chair. If bedrest is mandatory, elevate the head of the bed to a 90-degree angle.

• Avoid rushed or forced feeding. Adjust the rate of feeding and size of bites to the patient’s tolerance.

• Initiate a nutrition consult for appropriate diet modification such as chopping, mincing, or pureeing of foods and liquid consistency.

contain all the items on a clear liquid diet. Additional items allowed include milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. A full liquid diet contains liquids that can be poured at room temperature. High-calorie, high-protein supplements are recommended if a full liquid diet is used for more than 3 days.

The following measures may provide comfort to patients who are ordered NPO:

an abnormal accumulation of ketone bodies that is frequently associated with acidosis. Although an exact requirement for carbs has not been established, at least 50 to 100g are needed daily to prevent ketosis.

lipid

minerals

nasogastric (NG) tube

is inserted through the nose and into the stomach. However, the patient is at risk for aspirating the tube feeding solution into the lungs, a disadvantage for using this route. Patients with a dysfunctional gag reflex, high risk of aspiration, gastric stasis, gastroesophageal reflux, nasal injuries, and those who are unable to have the head of the bed elevated during feedings are not candidates for nasogastric feeding.

Levin tube

Traditional nasogastric tubes are firm and large in diameter. One example is a Levin tube. A Levin tube is a flexible rubber or plastic single-lumen tube with holes at the stomach end and a connector at the opposing end. The connector allows for attachment to a feeding apparatus and medication administration.

Dobbhoff tube

a smaller, softer,more pliable polyurethane tube may be inserted via the nose into the stomach or small intestine. This type of tube is advantageous, providing greater patient comfort and less trauma to the nares. A Dobbhoff tube is an example of this type of tube. However, the smaller tube diametermakes checking tube placement and medication administration more difficult than with the larger-diameter tubes.

nasointestinal (NI) tube

is passed through the nose and into the upper portion of the small intestine. It may be indicated for a patient with increased risk for aspiration due to a diminished gag reflex or slow gastric motility. Administration of the feeding solution into the small intestine also avoids the potential for gastric reflex. Some medical conditions (delayed gastric emptying, gastric tumor) also necessitate the use of a nasointestinal tube.

dumping syndrome

When formula is delivered directly into the intestine, a type of dumping syndrome may develop because the pyloric valve in the stomach, which normally slows transit of food into the intestine, is by passed. Rapid administration of hypertonic feeding solution into the proximal small intestine causes the movement of extracellular fluid from the vascular system into the small intestine. Distention of the small intestine occurs, with accompanying gas, bloating, nausea, diarrhea, cramping, and lightheadedness.

NPO

nutrients

specific biochemical substances used by the body for growth, development, activity, reproduction, lactation, health maintenance, and recovery from illness/injury. The metabolic processes involved in these functions are complex. Subsequently, most nutrients work better together than they do alone. Also, nutrient needs change throughout the life cycle in response to changes in body size, activity, growth, development, and state of health.

What are the six classes of nutrients? Which three supply energy and which three are needed to regulate body process?

Of the six classes of nutrients, three supply energy (carbohydrates, protein, lipids [fats]) and three are needed to regulate body processes (vitamins, minerals, water).

essential nutrients

called that because either they are not synthesized in the body or are made in insufficient amounts. Essential nutrients must be provided in diet or through supplements.

such as vitamins and minerals, are required in much smaller amounts to regulate and control body processes

nonessential nutrients

do not have to be supplied through dietary sources because they either are not required for body functioning or are synthesized in the body in adequate amounts. Some nutrients can be converted to others in the body. For instance, the body converts excess carbs and protein into fat and stores them as triglycerides.

nutrition

the study of how food nourishes the body. It encompasses the study of nutrients and how they are handled by the body as well as the impact of human behavior and environment on the process of nourishment. As such, this discipline involves physiology, psychology, and socioeconomics.

obesity

body weight 20% or more above ideal weight or having a BMI of 30 or more. A positive caloric balance, resulting from an excess caloric intake or a decrease in energy expenditure, leads to the gradual accumulation of weight. This excess weight increases the risk for numerous medical problems; increases the risks associated with surgery; increases the risk for complications during pregnancy, labor, and delivery; and increases morbidity and mortality. People who are obese are often discriminated against in social, educational, and employment settings.

nutritional assessment considerations for the older adult

biochemical data:

-low serum albumin lvl (below 3.5 mg/dL) may be a reflection of the aging process

-hemoglobin lvls that are lower than norm may only reflect anemia observed in elderly people as part of the aging process

Anthropometric data:

-because of age-related changes in body composition, skin-fold measurements, if used, should be taken from several body sites

DETERMINE--nutritional screening used for warning signs of poor nutritional health

-Disease: Any dz, illness, or chronic condition that causes a change in the way a person eats or makes it hard to eat

-Eating poorly: Eating too little/too much; skipping meals; eating the same foods all the time

-Tooth loss/mouth pain: Missing, loose, or rotten teeth or dentures that don’t fit well or cause mouth sores make it hard to eat

-Economic hardship: Having less/choosing to spend less on food makes it difficult to eat the foods needed to stay healthy

-Reduced social contact: Being with people has a positive effect on eating and well-being

-Multiple medicines: The more medicines taken, the greater the risk for side effedcts, such as incr/decr appetite, change in taste, constipation, weakness, drowsiness, diarrhea, and nausea. Vitamins and minerals taken in large doses act like drugs and can cause harm

-Involuntary weight loss/gain: A large weight loss/gain can be a sign of serious health probs

-Elder years above age 80: As age increases, risk of frailty and health probs increase

Mini Nutritional Assessment tool (MNA)

detect elderly persons at risk for malnutrition before changes in albumin level and the BMI. The MNA is a combination of screening questions followed by anthropometric measurements, including BMI, midarm and calf circumference, and weight loss. The MNA is fast and easy, and recommended for use with all elderly patients, whether they are community dwelling, hospitalized, or in long-term care settings

good indicator of a patient’s nutritional status a few weeks prior to when the blood is drawn and can help identify chronic nutrition problems. The albumin level does not change with increasing age, but malnutrition and various disease states cause its level to decrease. Serum albumin levels can also be affected by the patient’s hydration status; overhydration can cause a low albumin level and dehydration may cause a very high level.

Prealbumin levels

indicate short-term nutritional status and can be used to detect daily changes in a patient’s protein status.

transferrin

acts as an iron-transporting protein but because it is related to iron levels, may not always be an accurate indicator of nutritional status.

a breakdown product of amino acids, can be measured in the urine and blood. It reflects protein intake and the body’s ability to detoxify and excrete this metabolic byproduct

Creatinine levels

are directly proportional to the body’s muscle mass, and a reduction in this value reflects severe malnutrition.

parenteral nutition

percutaneous endoscopic gastrostomy tube (PEG)

is often used because, unlike a traditional, surgically placed gastrostomy tube, it usually does not require general anesthesia. Use of a PEG tube or other type of gastrostomy tube requires an intact, functional GI tract. Insertion of a PEG tube involves local anesthesia, passage of an endoscope into the stomach, a small incision or stab wound through the skin of the abdomen, pushing a cannula through the small incision, insertion of a guide wire or suture material through the cannula, and introduction and placement of the PEG tube through one of several methods.

PEG/J tube

In long-term feeding situations in which gastric problems exist, the jejunostomy is an alternate method through which nutrition can be delivered. These tubes may be inserted surgically or with endoscopic or laparoscopic guidance.

low-profile gastrostomy device (LPGD)

For patients who are active yet require long-term continuous or intermittent feedings. Children are also excellent candidates for LPGDs. The external apparatus is minimal and consists of a button or skin disk that is stable, less irritating to the skin, and has no external tubing so it is easier to conceal with clothing. Additional advantages include the fact that it can be immersed in water, is less noticeable, and is less likely to migrate or become dislodged. The device has a cap, which is opened to access the feeding tube and connect with the administration set.

peripheral parenteral nutrition (PPN)

protein

recommended dietary allowance (RDA) of essential nutrients

refers to recommendations for average daily amounts that healthy population groups should consume over time. Although an exact requirement for carbs has not been established, at least 50 to 100g are needed to prevent ketosis.

residual

soft diet

are usually regular diets that have been modified to eliminate foods that are hard to digest and to chew, including those that are high in fiber, high in fat, and highly seasoned. Soft diets may also be called bland or low-fiber diets. Soft diets are adequate in calories and nutrients and may be used on a long-term basis. (Foods excluded: • Raw fruits and vegetables• Coarse breads and cereals• Potentially gas-forming foods, such as cabbage and broccoli)

Fat-Restricted Diet

Low-fat diets are intended to lower the patient’s total intake of fat. This diet may be used, for example, with patients experiencing chronic cholecystitis (inflammation of the gallbladder) to decrease gallbladder stimulation and as part of dietary interventions for patients with cardiovascular disease, to help prevent atherosclerosis. Total amount of servings would be individually prescribed for each patient. (Foods excluded: • Whole milk, chocolate milk• Biscuits, pancakes, doughnuts, fritters, muffins• Whole-milk cheeses• Cake, pastry, pie, ice cream, chocolate• More than 1 egg/day, unless substituted for part of the meat allowed• Fat in excess of allowed amount• Avocado in excess of allowed amount• Fried meats, sausage, scrapple, hot dogs, spareribs, duck, peanut butter, salt pork, goose• All other soups• Any candy made with chocolate, nuts, butter, cream, or fat• Potato chips, fried potatoes, buttered, au gratin, or creamed vegetables)

pureed diet

Also known as a blenderized liquid diet because the diet is made up of liquids and foods blenderized to liquid form. Used after oral or facial surgery and for patients with chewing and swallowing difficulties. (Thickness and viscosity is based on patient tolerance.)

mechanical soft diet

Regular diet with modifications for texture. Used for patients with limited chewing ability or who have had surgery to the head, neck, or mouth. (Foods excluded: • Most raw fruits and vegetables• Foods containing seeds, nuts, dried fruit)

total parenteral nutrition (TPN)

trans fat

When manufacturers partially hydrogenate liquid oils, they become more solid and more stable. This substance is referred to as trans fat. Trans fat raises serum cholesterol. Therefore, it is to be counted in with the total number of saturated fats in a day. FDA requires that food nutrition labels must list trans fat so that consumers may make healthy choices in their diet.

triglyceride

vitamins

Obesity is defined as body weight
over ____ of the ideal.

20%

In which of the following patients
would the nurse expect to see a dec. in
BP?

1. anxious patient

2. patient scheduled for surgery

3. severe head injury

4. client who hemorrhaged after
surgery

4. pt who hemorrhaged after surgery.

Your client is placed on a FL diet.
Name some items found on his/ her tray?

Ice cream, sherbert, milk, custards, cream soups

What are the restrictions for a
cardiac diet

Fats, NA, caffeine

A common finding often noted in the
client receiving TPN

Inc glucose

A client with CAD or SHF may beinstructed on which type of diet?

NAS 2gram NA low chol, no caffeine

List the appropriate interventions
for a client receiving an enteral (tube) feeding

Hob 45-90, check pat and placement,

flush, check resid, shut off tf

when doing ADL’s or lying supine

A patient with parkinson’s
is experiencing dysphagia. What is the most serious risk associated with
this situation?